Evaluation of clinical ethics in Iranian hospitals: Employing a 360° approach—A cross‐sectional study

Abstract Background and Aims Clinical ethics is defined as recognizing and resolving value conflicts that arise from providing care in medical centers. This study aimed to evaluate the practice of clinical ethics in Iranian hospitals with a 360° approach. Methods The study was conducted by employing a descriptive‐analytical method in 2019. The statistical population included staff, patients, and managers of public, private, and insurance hospitals in Mazandaran province. The sample size for each group was 317, 729, and 36, respectively. The data collection tool was a researcher‐made questionnaire. The appearance and content validity of the questionnaire were confirmed by expert opinion and construct validity was confirmed by confirmatory factor analysis. The reliability was confirmed by Cronbach's alpha coefficient. Data were analyzed by one‐way analysis of variance and Tukey's post‐hoc test. We used SPSS software version 21 to analyse the data. Results The obtained mean score of clinical ethics from the perspective of service providers (0.56 ± 4.45) was higher than the perspective of service presenters (4.35 ± 0.65) and service recipients (0.79 ± 4.22), which was statistically significant (p < 0.05). Among the eight dimensions of clinical ethics, respect for the patient's right (0.68 ± 4.09) illustrated the highest score and medical error management (0.63 ± 4.33) presented the lowest score. Conclusion Based on the findings of the study, the level of clinical ethics in the hospitals of Mazandaran province is favorable, and among the dimensions of clinical ethics, respect for patient rights gained the lowest score and communication with other colleagues gained the highest score. Therefore, informing and teaching medical professionals in the field of clinical ethics, formulating binding laws, and paying serious attention to this issue in ranking and accrediting hospitals are recommended.


| INTRODUCTION
Considerable improvements in scientific and technological advances, especially in the field of medical sciences, have posed numerous ethical and legal challenges to healthcare providers. 1 Physicians, nurses, and other health team staff are faced with many new serious challenges 2 and sometimes forced to take actions to resolve the conflict with the patients, family members, or themselves as employees. 3 Regardless of the economic or social dimensions and goals, medicine as a profession is at risk of losing the reputation that society gives him. 4,5 Accordingly, the patient plays an essential role in the nature of the medical profession, and attention to his/her interests and circumstances in all aspects of medicine, and this is exactly where it seems to get the least attention. 6 Although considering the codes of ethics is necessary for all professions, as this indicator in the medical profession is even more obligatory as spiritual and responsible behavior with patients has a strong effect on improving and restoring their health. 7 Clinical ethics can be defined as the recognition, analysis, and resolution of value conflicts that arise during health care in hospitals and treatment centers. [8][9][10][11][12] Clinical ethics has traditionally focused on the issues such as informed consent, confidentiality and privacy, the ability to make decisions about disabled groups, and end-of-life care. 13 Although these issues remain a major concern, over the past two decades, we have seen an increase in the knowledge and importance of clinical ethics along with increasing concern in cases such as physician-assisted suicide, palliative care, medical errors, and genetic ethics. 14 Ethical considerations have been neglected in the provision of medical services, both in terms of policy-making and by service providers and even medical professionals.
Although healthcare organizations and policymakers believe a patient's entry into the treatment system means his or her consent to participate in this process, however, it should be noted that as much as in the subject of conscious consent to participate in the study, we emphasize consciousness of consent obtained from the subject of the study is, we must pay this attention when the patient participates in the treatment process. 15 Based on the results of research, the recognition of patients' rights by therapeutic staff was frequently violated and caused problems. 16 Studies state that the structure of the Iranian medical system shows suffers a lack of attention to various aspects of clinical ethics, so that the process of its development and progress in the field of health is slower than physical health issues. 17,18 Regarding the status of compliance of clinical ethics, different degrees have been reported, but most of the results have been moderate and unfavorable. In some studies, the ethical performance of service providers was evaluated poorly, 7,18 and in some others, was reported satisfactory. [19][20][21] The most important obstacles to comply with professional ethics were overcrowding of departments, insufficient health personnel (nurses and doctors), and inaccuracy due to heavy workload. 22,23 Similar results can be seen in other Middle Eastern countries, for example, in one study, the average score of moral sensitivity in Saudi doctors was 90.6 ± 19.6 24 and in another study, the use of clinical ethics consultation services in the hospital was considered insufficient. 25,26 In related studies in Pakistan, ethical knowledge among doctors was not satisfactory 27 and there was a need for a suitable management system and training of medical staff with compliance of ethical principles. 28 Although in recent years the health system in Iran has had continuous efforts to improve the conditions and standardize their services in hospitals, there has been no approach of ethics in hospitals consistent with the strategic approach. 15 For example, the role of hospital ethics committees and the description of their duties indicate a reductionism in the subject of ethics in the hospital. 3,29 On the other hand, despite the approval of the patients' rights charter, it has not yet been properly recognized and accepted. 30 It requires the provisions of the patients' rights charter, subject to the design of the assessment indicators of patient rights, public information, infrastructure development, staff training, legislation, and the establishment of patient rights protection units 31 and intrasectoral and multisectoral determination. 32 Therefore, strengthening the ethical skills besides increasing ethical knowledge among medical professionals is an important goal that must be seriously pursued. 33 Evaluating the status of clinical ethics component observance helps to identify the weaknesses and strengths in adhering to the principles of clinical ethics in service provider centers. It will help managers and officials active in the field of health services to identify deficiencies and subsequently make appropriate decisions to provide high-quality services and satisfy customers. Therefore, this study was conducted The scale of the questionnaire was a 5-point Likert spectrum scale. its range varies from "not taking enough action" to "complete progress in each field" (full compliance = 5, good compliance = 4, moderate compliance = 3, poor compliance = 2, noncompliance = 1).
The mean scores for each dimension were calculated with the opinion of related professors and other similar studies. Scores less than 3 were considered unfavorable, scores 3-4 were considered relatively desirable, and scores above 4 were considered favorable.
The mean total score of the questions in each dimension was considered as the score of that dimension. The total score of the questionnaire was calculated from the mean total scores of the total number of questions.
The reliability was assessed through a measure of internal consistency. Hence, Cronbach's α was calculated by data gathered had a master's degree, and 7.6% had a general practitioner ( Table 1).
The mean scores of clinical ethics are observed in three perspectives of service recipients, service presenters, and service providers ( Table 2). As results presented, the status of clinical ethics in the general public, insurance, and private hospitals of Mazandaran province was favorable (above 75%) and this rate was higher from the point of view of service providers than service presenters and service recipients and there is a significant difference among these three perspectives (p < 0.05).
The results of Table 3  The results of Table 4 illustrated that there is a significant difference between the views of recipients, presenters, and providers of health services in public and educational hospitals in all aspects of clinical ethics except respect for patient rights (p < 0.05).
The results of the two-way ANOVA (Table 5)   The presented level was more from the perspective of service providers than service presenters and service recipients, which was consistent with the results of another study on the significant difference between the evaluation of clinical ethics from the perspective of patients and the views of physicians and nurses. 34 Regarding that, a significant difference between two groups of presenters and providers was observed who are more familiar with different aspects of clinical ethics and has touched them consistently with the group of patients who are less in touch with the subject, which is quite "logical." The results of other studies presented that about 72% of nurses and 84% of physicians considered the general status of clinical ethics as positive 35 and patients' rights observance rates to be desirable, 36 were dissatisfied with both healthcare systems. 43 The results of another study showed that the rate of privacy for more than half of patients was at the middle level. 44 Another study showed that half of the patients expressed that their privacy has not been respected, 45 which is consistent with the results of the present study. Therefore, all the employees in the diagnostic and medical care departments are obligated to cooperate; since teamwork and mutual respect are the best ways to ensure that patients receive the benefits of the medical services provided. 54 T A B L E 3 Comparison of the views of recipients, presenters, and providers of health services. resources.

ACKNOWLEDGMENTS
The chiefs of hospitals in Mazandaran province who cooperated in this study are appreciated. The consent to send and publish the results of the study was received from the responsible authoritiesimplicitly or explicitly-in the hospitals of Mazandaran province where this study was conducted, before sending the results.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All data relevant to the study are included in the article.

ETHICS STATEMENT
The undertaken procedures were approved by the Medical Ethics Committee of Mazandaran University of Medical Sciences (IR.MA-ZUMS.REC.1398.5995). Written informed consent was obtained from all group members. Consent to submit has been received explicitly from all co-authors, as well as from the responsible authorities-tacitly or explicitly-at the institute/organization where the work has been carried out before the work is submitted. The purpose of this research was completely explained to the participants through the cover page of the questionnaire, and they were assured that their information would be kept confidential by the researcher.
Informed consent from the participants was acquired as they agreed to participate in the study by reviewing the questionnaire's cover page and clicking on the provided link. Furthermore, for participants younger than 18 years of age, the participant was asked for the consent of the parent or guardian.

TRANSPARENCY STATEMENT
The lead author Arash Ziapour affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.